Doctors Without Borders, January 7, 2016

Afghanistan: Nine Months Fighting Malnutrition in Helmand Province

The health care professionals often lack training and the quality of publicly available medicines is also dubious

Australian pediatric nurse Sam Templeman recently returned from Helmand Province, in the south of Afghanistan, where he worked with Doctors Without Borders/Médecins Sans Frontières (MSF) from December 2014 to September 2015. In the provincial capital city, Lashkar Gah, MSF supports the Ministry of Public Health's Boost Hospital. Here, Templeman discusses his experience.

"My mission was to supervise the general pediatric ward and inpatient therapeutic feeding center (a malnutrition ward, in other words), working alongside the Afghan Head of Department. The job involved a mix of direct hands-on care, bedside teaching, classroom teaching, as well as more managerial tasks such as rostering, supply/stock management, human resources, et cetera. I enjoyed being in a position with that sort of variety.

The focus of my assignment was to improve the quality of care our patients are receiving. We achieved it through staff training and supervision, renovation works, ensuring that we had the right resources/equipment, and also updating policies/procedures as necessary. Boost Hospital is quite a large one, and a large project by MSF standards. At Boost, MSF international nurses and doctors support Afghan staff in running the different departments—everything from surgery to intensive care and malnutrition wards. MSF employs almost 700 Afghan staff there.

In the general pediatric ward and inpatient therapeutic feeding center we have all female nurses and health assistants. I really appreciated working with our Afghan staff. I was always aware that it was quite a rare privilege to be able to work alongside and learn also from Afghan women. I was nervous at first, worried about saying or doing the wrong thing because we have different cultures, traditions . . . but I was quickly struck by how reactive they were. There was a nurse in the general pediatric ward who loves cricket. After the world cup I was told that because Australia won, I had to buy kebab for everyone working that day. My argument that since my country won, they should buy kebab for me, was not well received!

There is very little free health care in Helmand Province. Most people visit private clinics or pharmacies where they pay for treatment. The health care professionals often lack training and the quality of publicly available medicines is also dubious. Often people spend what little money they have on poor quality services. We see the knock-on effects of the lack of primary health care in the hospital, with many people presenting with ailments that do not need hospitalization.

The malnutrition ward brings many of the province’s issues into focus. Malnutrition is not caused simply through a lack of food. Anyone who’s been sick before can appreciate that you often lose your appetite and a bit of weight at the same time. But for a child in this context, without access to good primary health care, good nutrition, or adequate sanitation, this puts him or her at an increased risk of getting sick again. As this cycle repeats itself, a child ends up losing more and more weight until he is severely malnourished.

Another issue was the easy availability of antibiotics, which are often either inappropriately prescribed or bought without a prescription, thus fuelling antibiotic resistance. As these antibiotics become less and less effective, health outcomes will only get worse.

Difficult Cases

I remember a mother in the malnutrition ward whose son had kwashiorkor, a type of malnutrition where a child’s body becomes swollen. These children tend to have a higher risk of dying in hospital. We started him on the standard treatment and hoped to see the child improve and the swelling reduce. But there’s so much we still don’t know about malnutrition; so much research yet to be done. We went through other possible diagnoses, checked his urine and blood and did a chest X-ray to look for signs of tuberculosis. But nothing seemed to fit and we couldn’t work out why he wouldn’t respond.

But that’s not why I remember him. I remember him because of his mother. She was young, like so many were, and she cried for him. She cried and cried and didn’t stop because she was so worried about him. No one knew what to do. We were all so unused to seeing so much emotion; we didn’t know what to do for her.

Some of the other mothers tried to comfort her. Some of our staff tried to soothe her. In the first few days I sat with her and explained what was happening and that we expected him to improve after a few days of treatment. After a few days I had to tell her some children take longer to respond than others. Then that we were running some tests to look for other causes. And finally I didn’t know what to tell her. After about two weeks I was told she’d left and taken him to Pakistan hoping for better treatment. I’m not sure he survived the trip.

Constant Conflict

We would often hear fighting between armed groups and government forces. On one day, word spread that there’d been an explosion not far from the hospital. One of the nurses got a phone call from her sister telling her their house had been destroyed. Thankfully no one was hurt. She asked me if she could leave work early to see the damage and salvage what she could.

She’s one of the tougher nurses and usually gets on with work without complaint. Most people would be in tears after seeing their house destroyed but she managed to keep them at bay when she came back. Later that afternoon one of her patients died. She didn’t fall apart. At the end of the shift she put on her burka, took her bag, and went back to where her house used to stand. On her next shift, she showed up to work and worked as hard as she always did.

The international staff were not allowed out due to the tight security rules. We used to drive from our house through the bazaar to and from hospital and see people go about their business. We all longed to be able to get out and walk around, sit, and have a tea. I remember near the end of my assignment, one of the nurses asked if I’d ever been to the bazaar. I saw her colleagues shaking her head and making a gesture—something like 'only A to B,’ and then they started laughing. ‘Really?' one nurse said. 'You’ve never been anywhere except the hospital or your compound? In nine months?’

‘Once I went to a meeting,' I replied. 'I’m not allowed out.'

The nurse just couldn’t stop laughing. I sat there getting laughed at by this 19-year-old nurse for not being allowed out. That I did not like. My international colleagues, however, seemed to enjoy the story quite a lot.